MEDICARE: LAKE MICHIGAN DENTAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist		MI

General Provider Information

NPI Number	:	1164548640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE MICHIGAN DENTAL PC

Provider Business Mailing Address
First Line	:	2150 LAKE MICHIGAN DRIVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-4798
Country	:	US
Telephone Number	:	616-453-8211
Fax Number	:	616-453-3277

Provider Business Practice Location Address
First Line	:	2150 LAKE MICHIGAN DRIVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-4798
Country	:	US
Telephone Number	:	616-453-8211
Fax Number	:	616-453-3277

Authorized Official
Title or Position	:	PARTNER
Name	:	MICHAEL SCOTT PALASZEK
Credential	:	DDS
Telephone Number	:	616-453-8211

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	03/26/2012

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